AIDS and Behavior

, Volume 24, Issue 1, pp 65–80 | Cite as

Assessing the Efficacy of a PhotoVoice-Informed HIV Stigma Training for Health Care Workers

  • Mariam DavtyanEmail author
  • Scott M. Bartell
  • Cynthia M. Lakon
Original Paper


HIV stigma is a harmful social phenomenon present in United States (US)-based health care settings. This study assessed the efficacy of a participatory PhotoVoice-informed stigma reduction training program focusing on people living with HIV (PLWH) and targeting health care workers. Seventy-three (N = 73) participants were assessed at baseline (T1), within approximately a week of the training (T2), and at a 3-month follow-up (T3) regarding their HIV/AIDS knowledge, attitudes towards PLWH, and observations of enacted HIV stigma. Findings indicated that the training increased knowledge and improved attitudes (β = 0.56, p < 0.01; β = 0.58, p < 0.01, respectively) at T2, but these effects diminished at T3 (β = − 0.03, p > 0.05; β = − 0.29, p > 0.05, respectively). The training did not, however, have an impact on observations of enacted stigma at T2 (β = 0.10, p > 0.05) or at T3 (β = 0.02, p > 0.05). Additional participatory stigma reduction programs that involve diverse groups of health care workers, offer salient study incentives, include time-saving training methods, and comprise a variety of stigma measures, may be particularly beneficial.


PhotoVoice Participatory HIV stigma Training program Health care workers 



The authors express their sincere gratitude to the participants of this study for their invaluable contributions and to the University of California Irvine Newkirk Center for Science and Society for supporting this research.


The study was funded by the UC Irvine Newkirk Center for Science & Society.

Compliance with Ethical Standards

Conflict of interest

The authors confirm that there are no known conflicts of interest associated with this publication.


  1. 1.
    Nyblade L, Srinivasan K, Mazur A, et al. HIV stigma reduction for health facility staff: development of a blended-learning intervention. Front Public Health. 2018;6:165. Scholar
  2. 2.
    Stringer KL, Turan B, McCormick L, et al. HIV-related stigma among healthcare providers in the deep south. AIDS Behav. 2016;20(1):115–25. Scholar
  3. 3.
    Baugher AR, Beer L, Fagan JL, et al. Prevalence of internalized HIV-related stigma among HIV-infected adults in care, United States, 2011–2013. AIDS Behav. 2017;21(9):2600–8. Scholar
  4. 4.
    Travaglini LE, Himelhoch SS, Fang LJ. HIV stigma and its relation to mental, physical and social health among Black women living with HIV/AIDS. AIDS Behav. 2018;22(12):3783–94. Scholar
  5. 5.
    Katz IT, Ryu AE, Onuegbu AG, et al. Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis. J Int AIDS Soc. 2013;16:18640. Scholar
  6. 6.
    Earnshaw VA, Smith LR, Chaudoir SR, Amico KR, Copenhaver MM. HIV stigma mechanisms and well-being among PLWH: a test of the HIV stigma framework. AIDS Behav. 2013;17(5):1785–95. Scholar
  7. 7.
    Nyblade L, Hong KT, Anh NV, et al. Communities confront HIV stigma in Viet Nam: participatory interventions reduce HIV stigma in two provinces. Washington, DC: International Center for Research on Women; 2008.Google Scholar
  8. 8.
    Nyblade L, Stangl A, Weiss E, Ashburn K. Combating HIV stigma in health care settings: what works? J Int AIDS Soc. 2009;12(1):15. Scholar
  9. 9.
    Sprague L, Afifi R, Ayala G, El-nasoor ML. Participatory praxis as an imperative for health-related stigma research. BMC Med. 2019;17(1):32. Scholar
  10. 10.
    MacDonald C. Understanding participatory action research: a qualitative research methodology option. Can J Action Res. 2012;13(2):34–50.Google Scholar
  11. 11.
    Driessche KV, Sabue M, Dufour W, Behets F, Van Rie A. Training health care workers to promote HIV services for patients with tuberculosis in the Democratic Republic of Congo. Hum Resour Health. 2009;7(1):23. Scholar
  12. 12.
    Zarei N, Joulaei H, Darabi E, Fararouei M. Stigmatized attitude of healthcare providers: a barrier for delivering health services to HIV positive patients. Int J Commun Based Nurs Midwifery. 2015;3(4):292 PMID: 26448956.Google Scholar
  13. 13.
    Balfour L, Corace K, Tasca GA, et al. High HIV knowledge relates to low stigma in pharmacists and university health science students in Guyana, South America. Int J Infect Dis. 2010;14(10):e881–7. Scholar
  14. 14.
    Platten M, Pham HN, Nguyen HV. Knowledge of HIV and factors associated with attitudes towards HIV among final-year medical students at Hanoi medical university in Vietnam. BMC Public Health. 2014;14(1):265. Scholar
  15. 15.
    Hossain MB, Susan K. HIV-related discriminatory attitudes of healthcare workers in Bangladesh. J Health Popul Nutr. 2010;28(2):199.CrossRefGoogle Scholar
  16. 16.
    Geibel S, Hossain SM, Pulerwitz J, et al. Stigma reduction training improves healthcare provider attitudes toward, and experiences of, young marginalized people in Bangladesh. J Adolesc Health. 2017;60(2):S35–44. Scholar
  17. 17.
    Reidpath DD, Chan KY. HIV, stigma, and rates of infection: a rumour without evidence: authors’ reply. PLoS Med. 2007;4(1):e44. Scholar
  18. 18.
    Ramphoma KJ, Naidoo S. Knowledge, attitudes and practices of oral health care workers in Lesotho regarding the management of patients with oral manifestations of HIV/AIDS. S Afr dent. J. 2014;69(10):446–53.Google Scholar
  19. 19.
    Yousuf A, Shah AF, Jan SM, Sidiq M, Baba IA. Awareness of HIV/AIDS infection and ethical concerns amongst dentistry students and auxiliary staff in a hospital setup in Kashmir, India. Int J Commun Med Public Health. 2016;3(10):2850–5. Scholar
  20. 20.
    Davtyan M, Olshansky EF, Brown B, Lakon C. A grounded theory study of HIV-related stigma in US-based health care settings. J Assoc Nurses AIDS Care. 2017;28(6):907–22. Scholar
  21. 21.
    Dong X, Yang J, Peng L, et al. HIV-related stigma and discrimination amongst healthcare providers in Guangzhou, China. BMC Public Health. 2018;18(1):738. Scholar
  22. 22.
    Dias S, Gama A, Simões D, Mendão L. Implementation process and impacts of a participatory HIV research project with key populations. Biomed Res Int. 2018. Scholar
  23. 23.
    Wang C, Burris MA. Photovoice: concept, methodology, and use for participatory needs assessment. Health Educ Behav. 1997;24(3):369–87. Scholar
  24. 24.
    Nykiforuk CI, Vallianatos H, Nieuwendyk LM. Photovoice as a method for revealing community perceptions of the built and social environment. Int J Qual Methods. 2011;10(2):103–24 PMID: 27390573.CrossRefGoogle Scholar
  25. 25.
    Schell K, Ferguson A, Hamoline R, Shea J, Thomas-Maclean R. Photovoice as a teaching tool: learning by doing with visual methods. Int J Teach Learn High Educ. 2009;21(3):340–52.Google Scholar
  26. 26.
    Teti M, Murray C, Johnson L, Binson D. Photovoice as a community-based participatory research method among women living with HIV/AIDS: ethical opportunities and challenges. J Empir Res Hum Res Ethic. 2012;7(4):34–43. Scholar
  27. 27.
    Moletsane R, Mitchell C, de Lange N, et al. What can a woman do with a camera? Turning the female gaze on poverty and HIV and AIDS in rural South Africa. Int J Qual Stud Educ. 2009;22(3):315–31. Scholar
  28. 28.
    Davtyan M, Farmer S, Brown B, Sami M, Frederick T. Women of color reflect on HIV-related stigma through PhotoVoice. J Assoc Nurses AIDS Care. 2016;27(4):404–18. Scholar
  29. 29.
    Kubicek K, Beyer W, Weiss G, Kipke MD. Photovoice as a tool to adapt an HIV prevention intervention for African American young men who have sex with men. Health Promot Pract. 2012;13(4):535–43. Scholar
  30. 30.
    Misir P. Structuration theory: a conceptual framework for HIV/AIDS stigma. J Int Assoc Provid AIDS Care. 2015;14(4):328–34. Scholar
  31. 31.
    Giddens A. The constitution of society: outline of the theory of structuration. Berkeley: University of California Press; 1984.Google Scholar
  32. 32.
    Geter A, Herron AR, Sutton MY. HIV-related stigma by healthcare providers in the United States: a systematic review. AIDS Patient Care STDS. 2018;32(10):418–24. Scholar
  33. 33.
    Rice WS, Turan B, Fletcher FE, et al. A mixed methods study of anticipated and experienced stigma in health care settings among women living with HIV in the United States. AIDS Patient Care STDS. 2019;33(4):184–95. Scholar
  34. 34.
    Gutierrez CS, Wolff B. Using photovoice with undergraduate interprofessional health sciences students to facilitate understanding of and dialogue about health disparities within communities. Pedagogy Health Promot. 2017;3(1):42–9. Scholar
  35. 35.
    Teti M, Schulhoff AM, Koegler E, et al. Exploring the use of photo-stories and fiction writing to address HIV stigma among health professions students. Qual Health Res. 2019;29(2):260–9. Scholar
  36. 36.
    Eaton LA, Driffin DD, Kegler C, et al. The role of stigma and medical mistrust in the routine health care engagement of black men who have sex with men. Am J Public Health. 2015;105(2):e75–82. Scholar
  37. 37.
    Rogers SJ, Tureski K, Cushnie A, et al. Layered stigma among health-care and social service providers toward key affected populations in Jamaica and The Bahamas. AIDS Care. 2014;26(5):538–46. Scholar
  38. 38.
    Yiu JW, Mak WW, Ho WS, Chui YY. Effectiveness of a knowledge-contact program in improving nursing students’ attitudes and emotional competence in serving people living with HIV/AIDS. Soc Sci Med. 2010;71(1):38–44. Scholar
  39. 39.
    Derose KP, Bogart LM, Kanouse DE, et al. An intervention to reduce HIV-related stigma in partnership with African American and Latino churches. AIDS Educ Prev. 2014;26(1):28–42. Scholar
  40. 40.
    Shah SM, Heylen E, Srinivasan K, Perumpil S, Ekstrand ML. Reducing HIV stigma among nursing students: a brief intervention. West J Nurs Res. 2014;36(10):1323–37. Scholar
  41. 41.
    Stewart KE, DiClemente RJ, Ross D. Adolescents and HIV: theory-based approaches to education of nurses. J Adv Nurs. 1999;30(3):687–96. Scholar
  42. 42.
    Batey DS, Whitfield S, Mulla M, et al. Adaptation and implementation of an intervention to reduce HIV-related stigma among healthcare workers in the United States: piloting of the FRESH workshop. AIDS Patient Care STDS. 2016;30(11):519–27. Scholar
  43. 43.
    Andrewin A, Chien LY. Stigmatization of patients with HIV/AIDS among doctors and nurses in Belize. AIDS Patient Care STDS. 2008;22(11):897–906. Scholar
  44. 44.
    Ekstrand ML, Ramakrishna J, Bharat S, Heylen E. Prevalence and drivers of HIV stigma among health providers in urban India: implications for interventions. J Int AIDS Soc. 2013;16:18717. Scholar
  45. 45.
    Ahsan Ullah AK. HIV/AIDS-related stigma and discrimination: a study of health care providers in Bangladesh. J Int Assoc Phys AIDS Care. 2011;10(2):97–104. Scholar
  46. 46.
    Famoroti TO, Fernandes L, Chima SC. Stigmatization of people living with HIV/AIDS by healthcare workers at a tertiary hospital in KwaZulu-Natal, South Africa: a cross-sectional descriptive study. BMC Med Ethics. 2013;14(1):S6. Scholar
  47. 47.
    Carey MP, Schroder KE. Development and psychometric evaluation of the brief HIV Knowledge Questionnaire. AIDS Educ Prev. 2002;14(2):172–82 PMID: 12000234.CrossRefGoogle Scholar
  48. 48.
    Nyblade L, Jain A, Benkirane M, et al. A brief, standardized tool for measuring HIV-related stigma among health facility staff: results of field testing in China, Dominica, Egypt, Kenya, Puerto Rico and St. Christopher & Nevis. J Int AIDS Soc. 2013;16:18718. Scholar
  49. 49.
    Feyissa GT, Abebe L, Girma E, Woldie M. Stigma and discrimination against people living with HIV by healthcare providers, Southwest Ethiopia. BMC Public Health. 2012;12(1):522. Scholar
  50. 50.
    Kalichman SC, Simbayi LC, Jooste S, Toefy Y, Cain D, Cherry C, Kagee A. Development of a brief scale to measure AIDS-related stigma in South Africa. AIDS Behav. 2005;9(2):135–43. Scholar
  51. 51.
    Health Policy Project. Measuring HIV stigma and discrimination among Health Facility Staff: comprehensive questionnaire. 2013 Apr.Google Scholar
  52. 52.
    Wilson PA, Hansen NB, Tarakeshwar N, Neufeld S, Kochman A, Sikkema KJ. Scale development of a measure to assess community-based and clinical intervention group environments. J Commun Psychol. 2008;36(3):271–88. Scholar
  53. 53.
    Abler L, Henderson G, Wang X, et al. Affected by HIV stigma: interpreting results from a population survey of an urban center in Guangxi, China. AIDS Behav. 2014;18(2):192–201. Scholar
  54. 54.
    Keselman A, Kaufman DR, Patel VL. “You can exercise your way out of HIV” and other stories: the role of biological knowledge in adolescents’ evaluation of myths. Sci Educ. 2004;88(4):548–73. Scholar
  55. 55.
    Tenkorang EY, Owusu AY. Examining HIV-related stigma and discrimination in Ghana: what are the major contributors? Sex Health. 2013;10(3):253–62. Scholar
  56. 56.
    Werremeyer AB, Aalgaard-Kelly G, Skoy E. Using Photovoice to explore patients’ experiences with mental health medication: a pilot study. Ment Health Clin. 2016;6(3):142–53. Scholar
  57. 57.
    Vélez-Grau C. Using photovoice to examine adolescents’ experiences receiving mental health services in the United States. Health Promot Intl. 2018. Scholar
  58. 58.
    Mak WW, Cheng SS, Law RW, Cheng WW, Chan F. Reducing HIV-related stigma among health-care professionals: a game-based experiential approach. AIDS Care. 2015;27(7):855–9. Scholar
  59. 59.
    Williams AB, Wang H, Burgess J, et al. Effectiveness of an HIV/AIDS educational programme for Chinese nurses. J Adv Nurs. 2006;53(6):710–20. Scholar
  60. 60.
    Florom-Smith AL, De Santis JP. Exploring the concept of HIV‐related stigma. Innursing forum 2012 Jul (Vol. 47, No. 3). Malden: Blackwell; 2012. p. 153–65. Scholar
  61. 61.
    Pisal H, Sutar S, Sastry J, et al. Nurses’ health education program in India increases HIV knowledge and reduces fear. J Assoc Nurses AIDS Care. 2007;18(6):32–43. Scholar
  62. 62.
    Mahendra VS, Gilborn L, Bharat S, et al. Understanding and measuring AIDS-related settings: a developing country perspective. Sahara J. 2007;4(2):616–25 PMID:18071613.CrossRefGoogle Scholar
  63. 63.
    Ekstrand ML, Bharat S, Ramakrishna J, Heylen E. Blame, symbolic stigma and HIV misconceptions are associated with support for coercive measures in urban India. AIDS Behav. 2012;16(3):700–10. Scholar
  64. 64.
    Nebhinani N, Mattoo SK, Wanchu A. HIV stigma and specified correlates in North India. Indian J Psychol Med. 2012;34(4):324. Scholar
  65. 65.
    Beaulieu M, Adrien A, Potvin L, Dassa C. Stigmatizing attitudes towards people living with HIV/AIDS: validation of a measurement scale. BMC Public Health. 2014;14(1):1246. Scholar
  66. 66.
    Straetemans M, Bakker MI, Mitchell EM. Correlates of observing and willingness to report stigma towards HIV clients by (TB) health workers in Africa. Int J Tuberc Lung Dis. 2017;21(11):S6–18. Scholar
  67. 67.
    Marshall SA, Brewington KM, Allison MK, Haynes TF, Zaller ND. Measuring HIV-related stigma among healthcare providers: a systematic review. AIDS Care. 2017;29(11):1337–45. Scholar
  68. 68.
    Davtyan M, Olshansky EF, Lakon C. Addressing HIV stigma in health care. Am J Nurs. 2018;118(3):11. Scholar
  69. 69.
    Estabrooks P, You W, Hedrick V, Reinholt M, Dohm E, Zoellner J. A pragmatic examination of active and passive recruitment methods to improve the reach of community lifestyle programs: the talking health trial. Int J Behav Nutr Phys Act. 2017;14(1):7. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Mariam Davtyan
    • 1
    Email author
  • Scott M. Bartell
    • 2
  • Cynthia M. Lakon
    • 2
  1. 1.LAC+USC Maternal, Child & Adolescent/Adult Center for Infectious Diseases and Virology, Department of Pediatrics, Keck Medicine of USCUniversity of Southern CaliforniaLos AngelesUSA
  2. 2.Program in Public Health, Department of Population Health and Disease PreventionUniversity of California IrvineIrvineUSA

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